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    Document   : Incident2
    Created on : Jul 2, 2011, 1:33:54 AM
    Author     : Nadesh
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<h1 align="center">Surveillance of DF-DFH - Case Investigation Form cont..</h1>
<p align="center" class="Level2">EPIDIMIOLOGY UNIT, MINISTRY OF HEALTH</p>
<blockquote>
  <blockquote>
    <blockquote>
      <p>&nbsp;</p>
      <p><strong>B. PRESENT ILLNESS/OUTCOME</strong></p>
      <form id="Incident2" name="Incident2" method="post" action="/EpidStats/AddIncident">
      <p>8) Date of onset (dd mm yyyy):
        <input name="od1" type="text" id="od1" size="1" maxlength="1" />
        <input name="od2" type="text" id="od2" size="1" maxlength="1" />
        &nbsp;
        <input name="om1" type="text" id="om1" size="1" maxlength="1" />
        <input name="om2" type="text" id="om2" size="1" maxlength="1" />
        &nbsp;
        <input name="oy1" type="text" id="oy1" size="1" maxlength="1" />
        <input name="oy2" type="text" id="oy2" size="1" maxlength="1" />
        <input name="oy3" type="text" id="oy3" size="1" maxlength="1" />
        <input name="oy4" type="text" id="oy4" size="1" maxlength="1" />
      </p>
      <p>9) Patient Initially Treated from:
      </p>
      
        <p>
          <label>
            <input type="checkbox" name="treated" value="Government Hospital" id="treated_0" />
            Government Hospital</label>
          <br />
          <label>
            <input type="checkbox" name="treated" value="Private Hospital/practicioner" id="treated_1" />
            Private Hospital/practicioner</label>
          <br />
          <label>
            <input type="checkbox" name="treated" value="Others" id="treated_2" />
            Others</label>
          
          <br />
        </p>
     
      <p>10) Date of admission (dd mm yyyy):
        <input name="ad1" type="text" id="ad1" size="1" maxlength="1" />
        <input name="ad2" type="text" id="ad2" size="1" maxlength="1" />
        &nbsp;
        <input name="am1" type="text" id="am1" size="1" maxlength="1" />
        <input name="am2" type="text" id="am2" size="1" maxlength="1" />
        &nbsp;
        <input name="ay1" type="text" id="ay1" size="1" maxlength="1" />
        <input name="ay2" type="text" id="ay2" size="1" maxlength="1" />
        <input name="ay3" type="text" id="ay3" size="1" maxlength="1" />
        <input name="ay4" type="text" id="ay4" size="1" maxlength="1" />
      </p>
      <p>&nbsp; </p>
      <table width="491" border="0">
        <tr>
          <td width="211">11)  Ward no:
          <input name="ward" type="text" id="ward" size="10" maxlength="10" /></td>
          <td width="264">12)  BHT no:
            <input name="bht" type="text" id="bht" size="10" maxlength="10" /></td>
        </tr>
      </table>
      <p>13) Outcome:
        <label>
          <input name="outcome" type="radio" id="outcome_3" value="Discharged" checked="checked" />
          Discharged</label>
        <label>
          <input type="radio" name="outcome" value="Transfered" id="outcome_4" />
          Transfered</label>
        <label>
          <input type="radio" name="outcome" value="Died" id="outcome_5" />
          Died</label>
        <label>
          <input type="radio" name="outcome" value="Unknown" id="outcome_6" />
          Unknown</label>
        <label><br />
          <br />
14) Date of discharge, transfer or death (dd mm yyyy):
  <input name="dd1" type="text" id="ad3" size="3" maxlength="1" />
  <input name="dd2" type="text" id="ad4" size="3" maxlength="1" />
&nbsp;
<input name="dm1" type="text" id="am2" size="3" maxlength="1" />
<input name="dm2" type="text" id="dm2" size="3" maxlength="1" />
&nbsp;
<input name="dy1" type="text" id="ay2" size="3" maxlength="1" />
<input name="dy2" type="text" id="dy2" size="3" maxlength="1" />
<input name="dy3" type="text" id="oy9" size="3" maxlength="1" />
<input name="dy4" type="text" id="oy10" size="3" maxlength="1" />
<br />
          <br />
        </label>
        
      </p>
      <br/>
      <p align="left"><a href="/EpidStats/Incident1.jsp">Prev</a>
     </p>
     
      <blockquote>
        <blockquote>
            <div align="center">
              <input type="submit" name="submit" id="submit" value="Submit" /> &nbsp;&nbsp;
              <input type="submit" name="submit" id="submit" value="Cancel" />
            </div>
          </form>
          <p align="right">&nbsp;</p>
          <hr align="center" />
          </hr>
          <div align="center" class="small-font">&copy; copyright 2011| Epidemiology Unit | all right reserved</div>
          <p align="right">&nbsp;</p>
        </blockquote>
      </blockquote>
    </blockquote>
  </blockquote>
</blockquote>
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